Cracked Nipple

A cracked nipple is a full thickness break or deep crack across the skin of the nipple, often with bleeding and a scab, that causes severe pain with feeding. It follows untreated fissures, prolonged poor latch, vigorous infant suck, pump trauma, infant biting and skin conditions such as eczema. It matters because the open wound is an entry for bacteria and Candida, and pain leads to early weaning.

• Risk factors: untreated nipple fissure, tongue tie, engorgement, tight latch, oversized or undersized breast shields, eczema, dry skin, harsh creams, long feeds.
• Cracks may extend across the nipple and into the areola.
• Healing takes 7 to 21 days when the cause is corrected.

Women have severe stinging or burning pain on latching and throughout the feed, with a visible deep crack, scab or bleeding, and blood in the infant's mouth or milk. The nipple may look pinched or distorted after a feed.

• Deep crack across the nipple with raw base or yellow crust.
• Redness and swelling of the nipple and areola.
• Differential diagnosis: simple nipple fissure, nipple candidiasis, bacterial infection, herpes simplex, eczema, contact dermatitis, Paget disease of the breast, impetigo, traumatic nipple injury.
• Complications: bacterial infection, mastitis, abscess, bleeding, scar formation, nipple deformity, reduced milk supply, early weaning.

The diagnosis is clinical, with a feeding assessment and swabs where infection is suspected.

• Inspect the nipple before and after a feed for depth, extent, bleeding, discharge and signs of infection; photograph for review.
• Observe latch and the infant's mouth; check for tongue tie, high palate and poor suck.
• Swab for bacterial culture if pus, crust or slow healing; viral swab if grouped blisters; fungal culture or scraping if burning pain with pink shiny skin.
• Temperature; breast examination for mastitis; biopsy of any nipple lesion that does not heal in 3 weeks.

The principle is to rest and protect the wound, correct the cause of the injury, and treat infection early.

• Supportive: correct latch and positioning before every feed; feed from the less affected breast first; for deep painful cracks rest the nipple for 24 to 48 hours with hand expression and cup or spoon feeding of expressed milk, then restart feeds; moist wound healing with hydrogel dressings or purified lanolin after feeds; air dry briefly; protect the nipple from clothing friction; avoid soap, alcohol and perfumed creams; cleanse with water only.
• Pharmacological: paracetamol 1 g oral 6-hourly (maximum 4 g in 24 hours) and ibuprofen 400 mg oral 8-hourly with food, taken 30 minutes before feeds for 5 to 7 days; mupirocin 2 percent ointment applied thinly after each feed 3 times daily for 7 days when infection is suspected; flucloxacillin 500 mg oral 6-hourly for 7 to 10 days for spreading cellulitis or fever; clindamycin 300 mg oral 6-hourly for 7 to 10 days in penicillin allergy.
• Procedures: frenotomy of infant tongue tie; temporary nipple shield with lactation guidance.
• Special groups: infants with tongue tie or poor suck need assessment and frenotomy; women with diabetes need early treatment of infection and a full 10 day antibiotic course; breastfeeding continues during antibiotic treatment, and pauses on the affected side only if herpes lesions are on the nipple or breast.
• Red flags: fever above 38.5 degrees Celsius, spreading redness, pus, grouped vesicles, heavy bleeding, crack not healing by 3 weeks, nipple retraction or eczema like change, infant poor weight gain.
• Follow-up: review at 48 hours and 1 week; review infant weight at 1 week; swab results; breast examination at 6 weeks; biopsy for nonhealing lesion.